Attach 6 Activity Hazard Analysis FormBlank.pdf
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- Lower Columbia River Armed Security Services, Amend 0002 Federal contract opportunity
- Solicitation number
- W9127N25RA011
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E= Extremely High Risk H= High Risk M= Moderate Risk L= Low Risk S e v e r i t y
PROBABILTY
E E H H M E H H M L H M M L L M L L L L U.S. ARMY CORPS OF ENGINEERS, Portland District (NWP)
ACTIVITY HAZARDS ANALYSIS
Reference EM 385-1-1, Section 01.A.14/15 ; the proponent of this form is, CENWP-
RESIDUAL RISK ASSESSMENT CODE MATRIX
1.1 cyndie.d.coppenbarger@usace.army.mil Cyndie Coppenbarger NWP FORM 61_Activity Hazards Analysis_DEC_2022
28 DEC 2022
28 DEC 2022
ACE-IT FORMS TEAM
NWP FORM 61_Activity Hazards Analysis_DEC_2022 Page of
NWP FORM 61, DEC 2022
PREVIOUS EDITIONS ARE OBSOLETE
Print Employee Name Employee Signature * Date Print Employee Name Employee Signature * Date Page of
* Employee signatures certify they have read and understood the corresponding AHA.
NWP FORM 61, DEC 2022
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| Date the AHA was prepared.: |
| Date the AHA was revised.: |
| For multiple job steps, use the highest obtained Risk Code. Note: the risk code is the residual risk after controls have been implemented. The following codes require the appropriate personnel approvals: |
E = Division Commander (E = Extremely High Risk). Equates to loss of ability to accomplish mission if hazards occur during mission.
H = District Commander (H = High Risk). Results in significant degradation of mission capabilities if hazards occur during mission.
M = Program Manager, Project Manager, Project Engineer (M = Moderate). Minor injury, lost workday accident, compensable injury or illness, minor system damage, or minor property damage.
L = First Line Supervisor, Quality Assurance Representative (L = Low). Little or no impact on mission accomplishment.:
| Name of person(s) preparing this AHA form.: |
| Name of person(s) revising this AHA form.: |
| Name of person(s) that has reviewed this AHA form.: |
| AHANumber: |
| Describe specific job in which this AHA is being prepared, i.e.., Unit 2 Annual Maintenance: |
| If required, name of competent person who has reviewed the AHA.: |
| Work Order or Preventative Maintenance Number. Not required.: |
| Describe specific job in which this AHA form is being prepared for, i.e., Unit 2 Annual Maintenance: |
| If required, name of qualified person(s) who has reviewed the AHA.: |
| If required, name of certified person(s) who has reviewed the AHA.: |
| Signature of the competent person(s).: |
| Responsible person who has reviewed the AHA form for accuracy and completeness. Note: the AHA does not need to list minor hazards but should list major hazards most likely to result in personal injury, damage to property, materials, or the environment.: |
| Responsible person who has reviewed the AHA form for accuracy and completeness. Note: the AHA does not need to list minor hazards but should list major hazards most likely to result in personal injury, damage to property, materials, or the environment.: |
| Date the AHA was reviewed.: |
| Is a clearance required to perform this activity?: |
| Clearance number associated with this activity. Not Required. : |
| Are there chemical Safety Data Sheets (SDS) associated with this activity? : |
| Safety Data Sheet(s) attached to this AHA?: |
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| List any specialized training or certifications needed for the job.: |
| List any inspection requirements, before, during, or after the job is complete.: |
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